Medicare Secondary Payer (MSP) Tips

The information on this tip sheet addresses common MSP billing situations.

Send Claim To Medicare When:
Value Code
Other Codes
Medicare Payer Information
Beneficiary & Primary Payer Information
Primary Paid in Full on Inpatient Claim
Enter value code corresponding to type of primary payer with amount paid by primary payer
Enter condition code 77 to report provider accepts amount paid by primary as payment in full. No Medicare reimbursement will be made
Enter Medicare on  the second Payer line
Enter beneficiary and primary payer information exactly as reported on CWF
Primary Paid in Full on Outpatient Claim and Deductible Not Met
Enter value code corresponding to the type of primary payer with the amount paid by the primary payer
Enter condition code 77 to report provider accepts the amount paid by primary as payment in full. No Medicare reimbursement will be made
Enter Medicare on the second Payer line
Enter beneficiary and primary payer information exactly as reported on CWF
Primary Made Partial Payment
Enter value code corresponding to type of primary payer with amount paid by primary payer
If primary paid less than contractual amount (if applicable) and less than total charges, enter value code 44 with contractual amount
Enter Medicare on the second Payer line
Enter beneficiary and primary payer information exactly as reported on CWF
Primary Denied in Full — Send Claim for Conditional Payment
Enter value code corresponding to the type of primary payer with $0
Enter occurrence code 24 with the date of the primary insurance denial
Enter Medicare on the second Payer line
Enter beneficiary and primary payer information exactly as reported on CWF
Remarks field optional
No-fault or Liability, Primary Has Not Paid, and 120 Days Elapsed Since Accident/Claim
Enter value code corresponding to the type of primary payer with $0
Enter the occurrence code corresponding to the accident or injury. Do not use occurrence code 24
Enter Medicare on the second Payer line
Enter beneficiary and primary payer information exactly as reported on CWF
Remarks required
Beneficiary Refuses to Provide Primary Payer Information
Send claim to Medicare for primary payment. Enter condition code 08 to indicate refusal. Depending on the services provided, the claim may return to provider as beneficiary liable.
Beneficiary Unable to Provide Primary Payer Information and Provider Investigated Other Sources
Send a claim to Medicare for primary payment. The Benefits Coordination and Recovery Center (BCRC) will investigate as necessary to determine if another payer is primary to Medicare. (SE1416) (PDF, 93 KB)
 
Beneficiary Is Paid Directly by No-Fault Insurer
Report the amount paid by the primary insurer with appropriate coding.  Medicare will process as secondary payer and provider will need to look to the beneficiary for the primary payment resolution. IOM Pub. 100-5, Ch. 3, Section 10.1.1 Right of Providers to Charge Beneficiary Who Has Received Primary Payment from a GHP.

Note: The same time limit applies for filing MSP claims. We strongly recommend that you file MSP claims timely, even if you do not expect Medicare to make additional payment (secondary) payment.

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